Over the course of their lives, some patients develop chronic medical conditions. When commercial health insurers sign up new policy holders for their plans, they often exclude coverage for pre-existing conditions. With the enactment of the Patient Protection and Affordable Care Act of 2010 (PPACA), the commercial healthcare insurance industry in the United States is set to undergo a sea change in how pre-existing conditions are covered.

Prior to the PPACA, commercial health insurers could deny coverage for pre-exisiting conditions. Beginning in September, 2010, persons under the age of 19 can no longer be denied coverage if a dependent in the applicable age bracket is covered under his or her parents’ health insurance. Beginning in 2014, the policy will also apply to adult beneficiaries, regardless of their situation.

If the provisions of the PPACA go into effect, health insurers are forbidden to provide partial coverage or non-coverage for pre-existing medical conditions. Prior to the implementation date, the common exclusions for pre-existing conditions will still be in place. These include waiting periods before benefits go into effect, or higher deductibles or co-insurance for treatment of pre-existing conditions. Professional medical billers and certified medical coders are aware of how pre-existing conditions are reported to to insurers, and how these conditions effect coverage.

The codes that follow medical conditions in parentheses below are taken from the International Classification of Diseases-9th Edition-Clinical Modification (ICD-9-CM). This code book is currently the standard for reporting medical diagnoses to third-party insurance payers.

How Pre-Existing Conditions are Defined

When a person applies for health insurance, they fill out a questionnaire detailing their medical history. They may also have to undergo a physical examination by an approved healthcare provider to determine their current state of health. With this information, insurance companies may choose to exclude coverage for some conditions while still providing full coverage for routine or acute care unrelated to the pre-existing condition.

For example, a person diagnosed with benign high blood pressure, hypertension in medical parlance, (ICD-9-CM code 401.1) may apply for commercial health insurance. This person is being managed by his or her primary care provider on a regimen of two prescription medications. Because the insurance company is aware of this previously diagnosed and currently treated condition, the patient’s policy may be written to exclude coverage for treatment related to hypertension, as well as excluding payment for medications and treatments to manage the hypertension. The exclusion is rarely permanent; it normally lasts for one calendar year. Rather than a set exclusionary period, the patient’s policy may have a higher deductible or co-insurance for the pre-existing condition, increasing the patient’s out-of-pocket expense. Services that are unrelated to the condition, such as a gross hematuria (599.71) will be covered independently of the hypertension. Examination, follow-up testing, and treatments relating to hematuria will be covered at 100% of the patient’s subscribed benefits.

Again, this example is only relevant until the adult provisions of the PPACA go into effect, scheduled for 2014. If the legal challenges to the PPACA are successful, this will continue to be the standard of commercially insured care, as it has been for many years.

Correct Coding Identifies Pre-Existing Conditions

Conditions that effect commercial health insurance coverage are conditions that are ongoing at the time an insurance policy goes into effect. They are not conditions that were resolved in the past and for which patients are no longer receiving treatment.

A patient who has benign essential hypertension (401.1) may be excluded coverage during the exclusionary period for hypertension, but if a patient develops a different, though related, condition during the exclusionary period, such as Stage I hypertensive chronic kidney disease (403.00), it will be covered. While the two diseases may be related, the kidney disease is a separate condition that requires more extensive and different treatment than the pre-existing benign hypertension. Professional medical billers and certified medical coders report the patient’s diagnosis according to universally standard medical code. The correct code will enable the patient to take advantage of their full medical benefits.

Medical codes are assigned based on the available documentation in the patient’s medical record. If a healthcare provider documents that a patient is suffering from Stage I hypertensive chronic kidney disease, 403.00 is the code reported on the healthcare claim. If the healthcare provider examines the kidneys and runs appropriate tests to rule out the condition, a coder or biller can only assign the code for hypertension. The codes for malignant hypertension, benign hypertension, and unspecified essential hypertension (401.0, 401.1, and 401.9) all assume that hypertension is occurring without pre-existing kidney disease, according to the definition supplied by ICD-9-CM.

Medical coders and billers do not assign definitive diagnosis codes without a definitive diagnosis. If a condition has not yet been ruled in as affecting the patient, the justification for the ordered tests are the symptoms that justify the tests for being ordered. For instance, a urinalysis for hypertension will not be covered by insurance for a patient with this pre-existing condition. If the urinalysis is ordered for gross hematuria, it will be covered, because this is a distinct and independent service.

The patient’s medical record will include both diagnoses, hypertension and hematuria. When abstracting the written record into code, an astute and accurate medical biller will report that the hematuria was the primary reason for the encounter and the reason for the urinalysis. This is done in block 24 of the CMS-1500 claim form for professional claims. The lab requisition for the urinalysis, which is part of the patient’s medical record, will indicate that the test is ordered for hematuria.

The Importance of Coding and Billing Training

Even if pre-existing condition exclusions become a thing of the past, the accurate translation of medical encounters in standardized codes is the professional obligation of trained and certified medical coders and billers. It behooves them them to perform their duties with attention to detail in order to describe medical services as accurately as possible, not only so that patients receive their full insurance benefits, but also so that the healthcare reimbursement system remains transparent and effective.

Every day, medical claims are improperly denied because they are improperly coded. Professional medical billers and coders who bring the highest standard to their daily jobs do not worry about improper denials. When clean and accurate claims are submitted for payment, that payment is received in a timely manner, reducing the need for re-coding and resubmitting claims, and the need to appeal denials. This kind of professional performance can only be obtained through proper training.

A number of accredited programs are offered for people looking to enter the medical billing and coding field. With this baseline of professional knowledge, professional medical billers and certified medical coders continue their education over the course of their careers in order to provide a valuable administrative service to their employers. As the enactment of the PPACA shows, the healthcare reimbursement system is always changing. With a solid foundation of current knowledge regarding the industry, professionals in this demanding field will attain professional success while commanding salaries commensurate with their abilities.